Exchange/Medicaid/CHIP

Eligibility Appeals

Center for Medicaid and CHIP Services

Center for Consumer Information and Insurance Oversight

January 2013

NPRM Overview

• On Monday, January 14, CMS released a notice of proposed rule making

• Rule builds on final Medicaid/CHIP and Exchange rules released in

March 2012

• 30-Day public comment period – February 21, 2013

• Key Provisions

• Medicaid & CHIP eligibility, notices and appeals

• Medicaid Alternative Benefit Plans and Essential Health Benefits

• Appeals of Eligibility Determinations for Exchanges

• Medicaid and CHIP Eligibility Appeals

• Center for Medicaid and CHIP Services

Coordinated Appeals Options

• Integrated/delegated appeals: Medicaid/CHIP

agency delegates authority to make appeals

decisions to Exchange or Exchange appeals entity

• Bifurcated appeals/no delegation: State retains

appeals function

Integrated/Delegated Appeals

• Limited to MAGI-based determinations

• Individuals must be able to opt out of delegated hearing processes to

have their fair hearing conducted by the Medicaid agency

• State can retain right of review of the legal conclusions

• Exchange appeals entity must be governmental agency with merit

protection

• Coordinated decision

• Note: Medicaid can delegate appeals to the other state agencies by

seeking a waiver of single state agency requirements

Bifurcated Appeals/No Delegation

• No duplicate information requests

• Rely on findings of Exchange appeals entity, if based

on same process and standards applied by

Medicaid/CHIP agency

• Sequencing of hearings permitted – Medicaid hearing

decision may be issued no later than 45 days from

date of Exchange appeals decision

Coordination of Appeals

• Appeal of ATPC/CSR amount automatically triggers Medicaid/CHIP

appeal in certain circumstances:

• Final determination of Medicaid/CHIP ineligibility has been made by

Medicaid/CHIP agency

• Exchange has delegated authority to make Medicaid/CHIP eligibility

determinations

• No automatic appeal in assessment model if Medicaid/CHIP agency has

not denied eligibility

• Applies in both integrated and bifurcated options

Coordination of Appeals Cont.

• Information sharing through secure electronic interface

• Details worked out in written agreements

• Reinstatement of application (in assessment states only)

if the individual:

– Has withdrawn Medicaid application

– Is receiving APTC

– Then requests an appeal of the APTC level and

– The Exchange appeals entity finds the individual is potentially

eligible for Medicaid or CHIP

Coordination of Appeals Cont.

• Transmit Medicaid/CHIP appeals decision to the

Exchange when –

• Determination of Medicaid or CHIP ineligibility was made by

Exchange

• Determination of ineligibility was made by Medicaid or CHIP,

and account transferred to Exchange for APTC/CSR

eligibility determination

Other Appeals Modifications

• Individual choice of receiving electronic notice of appeal

rights

• Provides for accessibility of hearings process

• Clarifies 90 day timeframe for making appeals decision

• Miscellaneous clarifications: When a hearing must be

provided, matters to be addressed at hearing, definition

of “action”

Modernizing Appeals

• Modernizes current regulations related to appeals

• Request for a hearing: Provides for requests by

telephone, mail, in person, commonly used electronic

methods, including Internet Website (at state option)

• Expedited appeals process: For individuals when the

standard time frame might jeopardize health. Aligns

with existing managed care regulations

Scenario 1 Integrated Appeals/Delegation

Applicant applies through an Exchange

• The state has delegated eligibility determinations AND

appeals to the Exchange.

• Jane applies and is granted an APTC. She is an adult with

no children and has income at 150% FPL. The state covers

such adults to 133% FPL; Medicaid is denied. Jane

appeals her level of APTC to the Exchange.

• Jane’s appeal of APTC automatically triggers Medicaid fair hearing

request.

• Jane’s APTC and Medicaid appeals may be heard at the same time

by the Exchange appeals entity.

• Jane must be able to opt to have her Medicaid denial heard at the

Medicaid agency and informed how to do so.

Scenario 1 Cont. Integrated/Delegated Appeals

Assuming Jane does not opt for hearing by Medicaid agency:

• Jane’s appeal request of her APTC level is considered a

fair hearing request of her Medicaid denial.

• If the Exchange appeals entity decides that Jane’s income

is under 133% and thus eligible for Medicaid, the

Exchange appeals decision is final.

• Exchange appeals entity issues a combined decision on

the APTC/CSR and Medicaid issues.

• The state may establish a review process to review legal

conclusions.

Scenario 2 No Delegation/Bifurcated Appeals

• The state has delegated eligibility determinations, but

has not delegated appeals to the Exchange.

• Jane applies at Exchange and qualifies for APTC.

She is an adult with no children with income at 150%

FPL. The state covers such adults to 133% FPL;

Medicaid is denied. Jane appeals her level of APTC

to the Exchange.

• Jane’s APTC appeal will be at the Exchange appeals entity.

• Her Medicaid fair hearing will be at the Medicaid agency

Scenario 2 Cont. No Delegation/Bifurcated Appeals

• Jane’s appeal request of her APTC level is considered a fair hearing

request of her Medicaid denial.

• The agency may sequence hearings – the Exchange could decide

Jane’s case first, and the Medicaid agency have its hearing 2nd, and

issue a hearing decision no later than 45 days from date of Exchange

appeals decision.

• The Medicaid agency in conducting the hearing may not request

duplicate information already requested and provided by Jane to

Exchange appeals entity, and vice versa.

• The agency would rely on findings of Exchange appeals entity, if based

on same process and standards applied by Medicaid agency.

Scenario 3 Eligibility Assessment Approach

• The state has not delegated eligibility determinations to

the Exchange.

• Jane applies at Exchange, which assesses her as

ineligible for Medicaid. Jane is asked to (and does)

withdraw her Medicaid application. Jane is granted an

APTC. She is an adult with no children and is

determined to have income at 150% FPL. The state

covers such adults to 133% FPL;

• Jane later appeals her level of APTC. At the Exchange appeal,

the hearing officer finds that Jane had income below 133% and

is potentially eligible for Medicaid.

Scenario 3 Cont. Eligibility Assessment Approach

• Jane’s application for Medicaid is reinstated and is

transferred to the Medicaid agency to complete the

eligibility determination.

• If eligibility denied, any future appeal would be heard

by the Medicaid agency.

CHIP Appeals/Review Process

Similar options for CHIP programs with some program

specific modifications –

• Current broad flexibility to delegate CHIP review process

• Coordination requirements

• Reinstatement of application

• Beneficiaries must be informed of notice and appeal

rights

More Information

The NPRM is available at:

• https://www.federalregister.gov/articles/2013/01/22/2013-

00659/essential-health-benefits-in-alternative-benefit-

plans-eligibility-notices-fair-hearing-and-appeal